CERTIFICATION OF SERVICES RENDERED

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and such service was completed on ______ . I further certify that the amount of ___ is due for such service, and this amount is true, correct and unpaid. Signature.
CERTIFICATION OF SERVICES RENDERED

Date: _____________________

I

_____________________________ do hereby certify that the following service,

________________________________________________________________________ and such service was completed on _____________ . I further certify that the amount of

___

is due for such service, and this amount is true, correct and unpaid.

Signature

___________ Social Security Number

___________ Mailing Address

______________________ City, State, Zip Code